The Journal of Bone & Joint Surgery

The Journal of Bone & Joint Surgery, Volume 94, Issue 8

Instructional Course Lecture | April 18, 2012

Revision Open Capsular Shift for Atraumatic and Multidirectional Instability of the Shoulder

Aaron J. Bois, MD, MSc, FRCSC¹; Michael A. Wirth, MD¹

¹ The University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Drive, Mail Code 7774, San Antonio, TX 78229. E-mail address for A.J. Bois: bois@uthscsa.edu

View Disclosures and Other Information

Disclosure statement for author(s): PDF

Printed with permission of the American Academy of Orthopaedic Surgeons. This article, as well as other lectures presented at the Academy's Annual Meeting, will be available in March 2013 in Instructional Course Lectures, Volume 62. The complete volume can be ordered online at www.aaos.org, or by calling 800-626-6726 (8 a.m.-5 p.m., Central time).

An Instructional Course Lecture, American Academy of Orthopaedic Surgeons

Disclosure: None of the authors received payments or services, either directly or indirectly (i.e., via his or her institution), from a third party in support of any aspect of this work. One or more of the authors, or his or her institution, has had a financial relationship, in the thirty-six months prior to submission of this work, with an entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. No author has had any other relationships, or has engaged in any other activities, that could be perceived to influence or have the potential to influence what is written in this work. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the online version of the article.

J Bone Joint Surg Am, 2012 Apr 18;94(8):748-756. doi: 10.2106/JBJS.L00090

5 Recommendations (Recommend) | 3 Comments | Saved by 3 Users Save Case

Article

Comments (0)

text A A A

Extract

Shoulder stability is critical for proper functioning of the upper extremity and is dependent on the interplay between static and dynamic stabilizers of the glenohumeral joint. Surgical management of patients with atraumatic and multidirectional instability is effective if the capsular redundancy is properly reconstructed to restore glenohumeral joint biomechanics. Residual capsular laxity remains a common cause of recurrent glenohumeral joint dislocation in patients who have had previous stabilization procedures, and surgical results become less predictable in patients who have had multiple revision procedures. This article demonstrates the importance of the detection of capsular laxity at the time of the index surgery and of the use of reliable surgical techniques to obtain optimal results.

Figures in this Article

Introduction

Diagnosing Multidirectional Instability

The glenohumeral joint is one of the most frequently dislocated joints in humans¹. Shoulder instability is best understood as a spectrum of disease; traumatic unidirectional instability exists at one end of the spectrum, while atraumatic and multidirectional instability lies at the other extreme². Although capsular laxity is necessary to allow a wide range of glenohumeral motion, patients with multidirectional instability have pathologically increased capsular volume, which results in instability of the glenohumeral joint in more than one direction, primarily inferiorly^3-5. In contrast, patients with traumatic unidirectional instability are less likely to have abnormal capsular volumes, and more commonly have pathological lesions involving the capsulolabral complex^6,7.

Multidirectional instability was first described by Neer and Foster in 1980³ and is categorized into several clinical subtypes. Some patients may present with an inherited disorder of collagen, such as Ehlers-Danlos syndrome, and exhibit generalized ligamentous laxity, and others may have acquired instability following repetitive microtrauma as seen in baseball, swimming, or gymnastics². A small subset of patients may be able to dislocate their shoulders on command using techniques of asymmetric muscle pull or by developing improper muscle-firing patterns². These patients may have an accompanying psychiatric disorder or secondary gain issues that must be recognized and considered before recommending surgery because of their deleterious effects on surgical outcomes. Finally, patients with capsular insufficiency may present with pain as their only symptom, a condition known as the “unstable painful shoulder.”⁸

Diagnosing multidirectional instability can be challenging because of the wide spectrum of clinical presentations. Patients with classic multidirectional instability have symptomatic glenohumeral instability in more than one direction; however, there may be elements of both asymptomatic laxity and symptomatic instability in the same shoulder, and accurate differentiation between these two entities is crucial for surgical decision making². On physical examination, subtle differences between laxity and symptomatic instability can be delineated by specific maneuvers to detect anterior, posterior, and inferior capsular insufficiencies^3,9-11. The integrity of the inferior capsule and rotator interval should be assessed with use of the sulcus test³. With the affected arm in adduction and neutral rotation, the examiner grasps the distal aspect of the humerus just above the epicondyles and applies downward traction to the limb. In patients with inferior laxity, a sulcus is visible between the lateral acromial edge and the humeral head. Patients with inferior instability exhibit apprehension when the sulcus test is performed. To assess the rotator cuff interval, the maneuver is repeated with the arm in 30° of external rotation; if the sulcus decreases, the rotator interval is intact. Such a distinction is important because of the role of the rotator cuff interval in both posterior and inferior instability patterns¹². Although the diagnosis of multidirectional instability is dependent on a thorough history and physical examination, magnetic resonance arthrography is a useful adjunct to assess capsular redundancy and other soft-tissue and/or osseous causes of shoulder pain and dysfunction. This is especially important with the need for revision surgery¹³.

Nonoperative Treatment of Multidirectional Instability

Standard initial treatment of multidirectional instability is a rehabilitation program focused on rotator cuff strengthening, scapular stabilization, and proprioception exercises, in addition to activity modification¹¹. Nonoperative treatment was reported to be effective in 80% of patients compliant with an exercise program¹⁴; however, a recent long-term study of nonoperative treatment indicated that only 47% of patients had a satisfactory result on the basis of shoulder stability and Rowe scores, and only 64% had good to excellent results with regard to pain¹⁵. In 2010, Nyiri et al.¹⁶ reported that kinematic parameters and activity patterns of muscles around the glenohumeral joint can be normalized after surgery and physical therapy, but not with physical therapy alone. Whether these kinematic parameters and muscle activity patterns correlate clinically to better overall patient satisfaction and shoulder stability has yet to be determined. Regardless of the results of the latter two studies, the initial standard of care for patients with multidirectional instability is nonoperative rehabilitation; when such measures are unsuccessful, surgical options can be considered.

Revision Surgery Following Failed Stabilization Surgery

Traditionally, an open inferior capsular shift procedure is performed to address the capsular laxity that is present in multidirectional instability³; however, advances in arthroscopic techniques have revealed results comparable to those reported for open capsular shift^17-20 and primary Bankart repairs^21,22. With revision surgery, arthroscopic techniques are appropriate in properly selected patients to treat residual capsular laxity or to perform repeat Bankart repairs^23-25. Furthermore, arthroscopic examination should be considered before open reconstruction to allow the surgeon to identify and arthroscopically address other associated pathology found in patients with recurrent instability, including superior labral and rotator cuff tears^26,27.

Despite the advances in arthroscopic techniques, there is still a role for the open capsular shift procedure; the choice of surgical treatment is predominantly based on surgeon experience and individual patient pathology^28-30. Generally, open treatment is indicated for patients with specific soft-tissue pathology, including humeral avulsion of the glenohumeral ligaments³¹, midsubstance capsular rupture, capsular deficiency^32-34, and subscapularis deficiency (Fig. 1)³⁵. The latter two abnormalities are more common with revision surgery or after previous thermal capsulorrhaphy^29,35,36. In addition to soft-tissue pathology, osseous deficiency of the glenoid and/or humeral head³⁷ or abnormal glenoid version (Figs. 2-A through 2-D)³⁸ must be addressed with use of open reconstructive procedures to restore normal shoulder mechanics. Although uncommon in atraumatic instability or multidirectional instability, bone augmentation procedures are performed when bone loss exceeds approximately 25% to 30% of the posterosuperior humeral head (i.e., measured as a percentage of either the diameter of the humeral head or articular arc)^39-42 or anterior glenoid margin (i.e., anteroposterior diameter of inferior aspect of the glenoid)^43-46. Both humeral and glenoid bone loss can be quantified preoperatively, with advanced imaging such as computed tomography, or intraoperatively, with use of direct measurements or arthroscopic techniques.

Fig. 1

Operative technique for pectoralis major transfer for irreparable rupture of the subscapularis tendon. Stay sutures, which had been placed in the superior half of the pectoralis major tendon, are passed into a bone trough made lateral to the bicipital groove and out through cortical drill-holes. (Reproduced from: Wirth MA, Rockwood CA Jr. Operative treatment of irreparable rupture of the subscapularis. J Bone Joint Surg Am. 1997;79:722-31.)

View Large | Download Slide(.ppt)
Add to My JBJS

Fig. 2-A Fig. 2-B Fig. 2-C Fig. 2-D

Figs. 2-A Postoperative axial computed tomography scan revealing symmetrical glenoid version and incorporation of the tricortical bone graft (arrow) after a posterior opening wedge osteotomy of the glenoid for glenoid retroversion of approximately 50°. (Reproduced, with permission of Wolters Kluwer, from: Wirth MA, Seltzer DG, Rockwood CA Jr. Recurrent posterior glenohumeral dislocation associated with increased retroversion of the glenoid. A case report. Clin Orthop Relat Res. 1994;308:98-101.) Figs. 2-B, 2-C, and 2-D Clinical photographs demonstrating full and symmetrical motion. (Reproduced, with modification, from: Matsen FA III, Lippitt SB, Bertlesen A, Rockwood CA Jr, Wirth MA. Glenohumeral instability. In: Rockwood CA Jr, Matsen FA III, Wirth MA, Lippitt SB, editors. The shoulder. 4th ed. Philadelphia: WB Saunders; 2009. p 617-770. Reproduced with permission of Elsevier. Copyright 2009.)

View Large | Download Slide(.ppt)
Add to My JBJS

Surgical Techniques—Open Capsular Shift

Surgical efforts for shoulder instability are directed toward the specific pathoanatomy. In general, all pathological lesions involving the static and dynamic shoulder stabilizers must be identified and, when indicated, corrected simultaneously to restore shoulder mechanics. The primary goal of surgical management in patients with multidirectional instability typically involves shifting or imbricating the redundant inferior capsule to reduce excessive glenohumeral volume and restore joint stability³. These procedures should be combined with open Bankart repairs when indicated.

Open capsular shift procedures were originally performed with use of a laterally based capsular incision, through which the inferior capsule is shifted superiorly to reduce capsular volume and restore tension to the glenohumeral ligaments³. Modifications to the original open capsular shift procedure involve variations in the location of the capsulotomy and include medially based⁴⁷ and midline-based⁴⁸ techniques. The concept of a selective capsular shift was introduced to refine the final step of a standard open capsulolabral repair, in which the capsuloligamentous complex is tensioned with the arm in a position of approximately 30° of abduction and external rotation to selectively tension the capsule in a functional position^49,50.

The surgical technique for the midline capsular imbrication procedure⁴⁸ is performed through an axillary incision in the deltopectoral interval. The axillary nerve is identified along the anteroinferior border of the subscapularis muscle and is protected. With the arm in external rotation, the borders of the subscapularis tendon are identified and the superior two-thirds of the tendon is incised vertically 2 cm from its insertion on the lesser tuberosity. The tendon is incised down to but not into the capsule; Mayo scissors are used to reflect the medial part of the subscapularis tendon off the capsule.

The capsule is then divided vertically, midway between its attachments on the humeral neck and the glenoid rim (Fig. 3). The incision begins at the inferior border of the rotator interval and extends inferiorly beyond the six o'clock position. The more laxity in the posterior aspect of the capsule, the more the capsular incision should be extended posteriorly (Fig. 4). Stay sutures are placed sequentially along the free edge of the medial capsular leaflet; these sutures allow traction on the medial capsular leaflet, which makes it possible to divide the most posteroinferior portion of the inferior glenohumeral ligament complex. This degree of capsular incision allows subsequent anterior advancement of the posterior portion of the inferior glenohumeral ligament complex.

Fig. 3

Drawing showing the vertical division of the anterior capsule, midway between its attachments on the glenoid rim and humeral head. (Reproduced from: Wirth MA, Groh GI, Rockwood CA Jr. Capsulorrhaphy through an anterior approach for the treatment of atraumatic posterior glenohumeral instability with multidirectional laxity of the shoulder. J Bone Joint Surg Am. 1998;80:1570-8.)

View Large | Download Slide(.ppt)
Add to My JBJS

Fig. 4

Drawing showing a medial (en face) view of the glenoid fossa with attached glenohumeral joint capsule. The capsular incision (broken line) begins at the rotator interval superiorly and extends to the posteroinferior aspect of the capsule. (Reproduced from: Wirth MA, Groh GI, Rockwood CA Jr. Capsulorrhaphy through an anterior approach for the treatment of atraumatic posterior glenohumeral instability with multidirectional laxity of the shoulder. J Bone Joint Surg Am. 1998;80:1570-8.)

View Large | Download Slide(.ppt)
Add to My JBJS

After the capsulotomy is completed, the capsular tissue within the rotator interval is closed with a horizontal mattress suture (Fig. 5). This is followed by two capsular imbrication phases; during each phase, the arm is held in 25° of external rotation, 20° of abduction, and 0° of forward elevation. The first imbrication step shifts the medial aspect of the inferior glenohumeral ligament complex anteriorly and laterally, and the remaining portion of the medial aspect of the capsule is shifted laterally and superiorly under the lateral capsular leaflet. This step should eliminate any posterior capsular laxity. Next, the lateral aspect of the capsule is shifted superomedially and is sutured to the anterior surface of the medial aspect of the capsule (Fig. 6). If <30° of passive external rotation is present at the conclusion of the procedure, there has been excessive tightening of the anterior structures and the procedure may push the humeral head out posteriorly⁵¹.

Fig. 5

Drawing showing the placement of sutures along the medial capsular leaflet to allow traction (arrow) and permit division of the most posteroinferior capsular complex. These sutures are then passed through the lateral capsule as part of the first imbrication step. (Reproduced from: Wirth MA, Groh GI, Rockwood CA Jr. Capsulorrhaphy through an anterior approach for the treatment of atraumatic posterior glenohumeral instability with multidirectional laxity of the shoulder. J Bone Joint Surg Am. 1998;80:1570-8.)

View Large | Download Slide(.ppt)
Add to My JBJS

Fig. 6

Drawing demonstrating double-breasting of the lateral aspect of the capsule. (Reproduced from: Wirth MA, Groh GI, Rockwood CA Jr. Capsulorrhaphy through an anterior approach for the treatment of atraumatic posterior glenohumeral instability with multidirectional laxity of the shoulder. J Bone Joint Surg Am. 1998;80:1570-8.)

View Large | Download Slide(.ppt)
Add to My JBJS

Postoperatively, the patient wears a shoulder immobilizer for comfort. During this time, the patient is encouraged to use the involved extremity for activities of daily living and is instructed to exercise the hand, wrist, and elbow, but is cautioned to avoid adduction, forward elevation, and internal rotation maneuvers. Pendulum exercises are initiated at fourteen days; however, the stretching phase of the rehabilitation program is not started until six weeks after surgery. Muscle strengthening is initiated only after the patient has regained active elevation to within 20° to 30° of that of the normal side and rotation is about 50% to 60% of that of the normal side. The strengthening program is performed three or four times daily and emphasizes conditioning of the deltoid and rotator cuff muscles, as well as the muscles that stabilize the scapula.

Risk Factors for Failed Stabilization Procedures

The most common complication of any stabilization procedure, whether open or arthroscopic, is recurrent glenohumeral joint instability. In patients with multidirectional instability, surgical intervention is aimed at addressing the specific type of capsular laxity present^2,3,11. When the capsulolabral complex is not appropriately managed, higher failure rates have been reported^45,52-55.

Rowe et al.⁵² reviewed the intraoperative findings in thirty-two patients who underwent revision surgery for recurrent anterior instability. In that series, capsular laxity was found in 80% of the thirty-two shoulders with unsuccessful index surgery. In 1991, Young and Rockwood⁵³ reported a good or excellent outcome in only 50% of patients with revision anterior shoulder reconstruction following an unsuccessful Bristow procedure. At the time of revision surgery, thirty-two shoulders (80%) had excessive capsular laxity and eight (20%) had an untreated Perthes-Bankart lesion. In 2006, Boileau et al.⁴⁵ attempted to identify risk factors for recurrent instability following an arthroscopic stabilization procedure, and found that the presence of (1) a stretched inferior glenohumeral ligament, (2) anterior hyperlaxity, or (3) a glenoid compression fracture involving >25% of the glenoid surface led to a 75% recurrence rate. Balg and Boileau⁵⁶ later incorporated “shoulder hyperlaxity” as one of six risk factors listed as part of a 10-point “preoperative instability severity index score.” This preoperative checklist serves to identify patients at risk of developing recurrent instability after an arthroscopic Bankart procedure.

Failure to surgically address critical bone loss of the glenoid or humeral head has also been correlated with higher recurrence rates following isolated repairs of the capsulolabral complex in patients with recurrent instability^37,45,52,54. Rowe et al.⁵², in a review of twenty-nine shoulders with revision stabilization surgery, reported that a Hill-Sachs defect was found in twenty-three patients and a glenoid rim defect, in twenty-two patients. In addition to the capsular laxity in these patients, glenohumeral bone loss may have affected the results of the index instability procedure. Burkhart and De Beer³⁷, in their series of 194 patients who underwent a primary soft-tissue repair, reported twenty-one recurrent dislocations and subluxations; fourteen of those shoulders had substantial bone defects, including three engaging Hill-Sachs lesions and eleven inverted-pear glenoid lesions, for a combined recurrence rate of 67%. Boileau et al.⁴⁵ similarly found higher rates of postoperative recurrent instability in patients with considerable glenohumeral bone loss.

Results of Open Capsular Shift

The results after a primary capsular shift procedure addressing multidirectional instability are encouraging. Neer and Foster³ were the first, to our knowledge, to describe the surgical technique and early results of an open inferior capsular shift in thirty-six patients (forty shoulders) with involuntary multidirectional instability. Only one patient in that series experienced recurrent instability within the first year of follow-up. In 1992, Cooper and Brems⁵⁷ reported the results of an inferior capsular shift procedure using an anterior approach in thirty-eight patients (forty-three shoulders) with multidirectional instability. Overall, 89% of the patients were satisfied, with no recurrent instability after a minimum follow-up of two years. More recently, Pollock et al.⁵⁸ reported on forty-six patients (forty-nine shoulders) with multidirectional instability who had a mean of sixty-one months of follow-up after an inferior capsular shift. Good or excellent results were found in 94% of the shoulders, and 96% of the shoulders remained stable; however, the results were less favorable in athletes as only 69% of this cohort returned to their prior level of participation.

Less reliable results can be expected following revision stabilization surgery in patients with preexisting arthritis, an age of over thirty years, glenohumeral bone loss, residual capsular laxity, or a history of two or more unsuccessful surgical procedures for glenohumeral joint instability^59-64.

Zabinski et al.⁵⁹ evaluated the results of revision shoulder stabilization surgery in twenty patients (twenty-one shoulders) with multidirectional instability. At the time of the revision, the primary lesion in all patients was capsular laxity; a total of fifteen patients required a capsular shift procedure. At a mean follow-up of 61.5 months, only nine shoulders had good or excellent results despite multiple reoperations, with four requiring glenohumeral arthrodesis. Levine et al.⁶⁰ reported the results of revision anterior stabilization surgery in fifty patients. At the time of revision surgery, all patients required an anteroinferior capsular shift for residual capsular laxity. After an average of 4.7 years of follow-up, the results in eleven shoulders (22%) were considered unsatisfactory; factors associated with poor results included an atraumatic cause of failure, voluntary dislocations, unaddressed capsular laxity, and multiple prior stabilization procedures. Four of nine shoulders that had undergone more than one prior stabilization attempt had recurrent instability after the revision procedure compared with only seven (17%) of forty-one shoulders that underwent one prior stabilization procedure. Other investigators have found similar results for patients with multidirectional instability who had multiple unsuccessful stabilization procedures, with less predictable results in terms of postoperative pain relief⁶². In severe cases of multidirectional instability refractory to conservative management, a glenohumeral arthrodesis can be considered in this subgroup of young patients.

Overview

In general, good surgical outcomes can be achieved in patients with glenohumeral joint instability if the soft-tissue and osseous pathology identified during the primary stabilization surgery is appropriately addressed. Capsular abnormalities in atraumatic and multidirectional instability typically represent a combination of asymptomatic laxity and symptomatic instability. Open capsular shift procedures offer a reliable and effective surgical solution in appropriately selected patients with capsular redundancy; however, less favorable results should be expected following revision surgery in patients with multidirectional instability. Future work should be directed at improving the ability to diagnose and anatomically repair capsular redundancy at the time of index surgery to prevent the long-term adverse outcomes following revision surgery.

Zacchilli MA; Owens BD. Epidemiology of shoulder dislocations presenting to emergency departments in the United States. J Bone Joint Surg Am. 2010;92:542-9.

Lo IK; Bishop JY; Miniaci A; Flatow EL. Multidirectional instability: surgical decision making. Instr Course Lect. 2004;53:565-72.

Neer CS 2nd; Foster CR. Inferior capsular shift for involuntary inferior and multidirectional instability of the shoulder. A preliminary report. J Bone Joint Surg Am. 1980;62:897-908.

Mallon WJ; Speer KP. Multidirectional instability: current concepts. J Shoulder Elbow Surg. 1995;4(1 Pt 1):54-64.

Dewing CB; McCormick F; Bell SJ; Solomon DJ; Stanley M; Rooney TB; Provencher MT. An analysis of capsular area in patients with anterior, posterior, and multidirectional shoulder instability. Am J Sports Med. 2008;36:515-22.

Bankart ASB. The pathology and treatment of recurrent dislocation of the shoulder-joint. Br J Surg. 1938;26:23-9.

Stefko JM; Tibone JE; Cawley PW; ElAttrache NE; McMahon PJ. Strain of the anterior band of the inferior glenohumeral ligament during capsule failure. J Shoulder Elbow Surg. 1997;6:473-9.

Boileau P; Zumstein M; Balg F; Penington S; Bicknell RT. The unstable painful shoulder (UPS) as a cause of pain from unrecognized anteroinferior instability in the young athlete. J Shoulder Elbow Surg. 2011;20:98-106.

Gagey OJ; Gagey N. The hyperabduction test. J Bone Joint Surg Br. 2001;83:69-74.

Matsen FA 3rd; Chebli C; Lippitt S; American Academy of Orthopaedic Surgeons. Principles for the evaluation and management of shoulder instability. J Bone Joint Surg Am. 2006;88:648-59.

Bell JE. Arthroscopic management of multidirectional instability. Orthop Clin North Am. 2010;41:357-65.

Harryman DT 2nd; Sidles JA; Harris SL; Matsen FA 3rd. The role of the rotator interval capsule in passive motion and stability of the shoulder. J Bone Joint Surg Am. 1992;74:53-66.

Mohana-Borges AV; Chung CB; Resnick D. MR imaging and MR arthrography of the postoperative shoulder: spectrum of normal and abnormal findings. Radiographics. 2004;24:69-85.

Burkhead WZ Jr; Rockwood CA Jr. Treatment of instability of the shoulder with an exercise program. J Bone Joint Surg Am. 1992;74:890-6.

Misamore GW; Sallay PI; Didelot W. A longitudinal study of patients with multidirectional instability of the shoulder with seven- to ten-year follow-up. J Shoulder Elbow Surg. 2005;14:466-70.

Nyiri P; Illyés A; Kiss R; Kiss J. Intermediate biomechanical analysis of the effect of physiotherapy only compared with capsular shift and physiotherapy in multidirectional shoulder instability. J Shoulder Elbow Surg. 2010;19:802-13.

Duncan R; Savoie FH 3rd. Arthroscopic inferior capsular shift for multidirectional instability of the shoulder: a preliminary report. Arthroscopy. 1993;9:24-7.

Treacy SH; Savoie FH 3rd; Field LD. Arthroscopic treatment of multidirectional instability. J Shoulder Elbow Surg. 1999;8:345-50.

Gartsman GM; Roddey TS; Hammerman SM. Arthroscopic treatment of multidirectional glenohumeral instability: 2- to 5-year follow-up. Arthroscopy. 2001;17:236-43.

Sekiya JK; Willobee JA; Miller MD; Hickman AJ; Willobee A. Arthroscopic multi-pleated capsular plication compared with open inferior capsular shift for reduction of shoulder volume in a cadaveric model. Arthroscopy. 2007;23:1145-51.

Fabbriciani C; Milano G; Demontis A; Fadda S; Ziranu F; Mulas PD. Arthroscopic versus open treatment of Bankart lesion of the shoulder: a prospective randomized study. Arthroscopy. 2004;20:456-62.

Petrera M; Patella V; Patella S; Theodoropoulos J. A meta-analysis of open versus arthroscopic Bankart repair using suture anchors. Knee Surg Sports Traumatol Arthrosc. 2010;18:1742-7.

Kim SH; Ha KI; Kim YM. Arthroscopic revision Bankart repair: a prospective outcome study. Arthroscopy. 2002;18:469-82.

Patel RV; Apostle K; Leith JM; Regan WD. Revision arthroscopic capsulolabral reconstruction for recurrent instability of the shoulder. J Bone Joint Surg Br. 2008;90:1462-7.

Boileau P; Richou J; Lisai A; Chuinard C; Bicknell RT. The role of arthroscopy in revision of failed open anterior stabilization of the shoulder. Arthroscopy. 2009;25:1075-84.

Yiannakopoulos CK; Mataragas E; Antonogiannakis E. A comparison of the spectrum of intra-articular lesions in acute and chronic anterior shoulder instability. Arthroscopy. 2007;23:985-90.

Arrigoni P; Huberty D; Brady PC; Weber IC; Burkhart SS. The value of arthroscopy before an open modified latarjet reconstruction. Arthroscopy. 2008;24:514-9.

Cole BJ; L'Insalata J; Irrgang J; Warner JJ. Comparison of arthroscopic and open anterior shoulder stabilization. A two to six-year follow-up study. J Bone Joint Surg Am. 2000;82:1108-14.

Millett PJ; Clavert P; Warner JJ. Open operative treatment for anterior shoulder instability: when and why?J Bone Joint Surg Am. 2005;87:419-32.

Boselli KJ; Cody EA; Bigliani LU. Open capsular shift: there still is a role!Orthop Clin North Am. 2010;41:427-36.

Wolf EM; Cheng JC; Dickson K. Humeral avulsion of glenohumeral ligaments as a cause of anterior shoulder instability. Arthroscopy. 1995;11:600-7.

Iannotti JP; Antoniou J; Williams GR; Ramsey ML. Iliotibial band reconstruction for treatment of glenohumeral instability associated with irreparable capsular deficiency. J Shoulder Elbow Surg. 2002;11:618-23.

Warner JJ; Venegas AA; Lehtinen JT; Macy JJ. Management of capsular deficiency of the shoulder. A report of three cases. J Bone Joint Surg Am. 2002;84:1668-71.

Alcid JG; Powell SE; Tibone JE. Revision anterior capsular shoulder stabilization using hamstring tendon autograft and tibialis tendon allograft reinforcement: minimum two-year follow-up. J Shoulder Elbow Surg. 2007;16:268-72.

Wirth MA; Rockwood CA Jr. Operative treatment of irreparable rupture of the subscapularis. J Bone Joint Surg Am. 1997;79:722-31.

Wong KL; Williams GR. Complications of thermal capsulorrhaphy of the shoulder. J Bone Joint Surg Am. 2001;83 Suppl 2 Pt 2:151-5.

Burkhart SS; De Beer JF. Traumatic glenohumeral bone defects and their relationship to failure of arthroscopic Bankart repairs: significance of the inverted-pear glenoid and the humeral engaging Hill-Sachs lesion. Arthroscopy. 2000;16:677-94.

Wirth MA; Seltzer DG; Rockwood CA Jr. Recurrent posterior glenohumeral dislocation associated with increased retroversion of the glenoid. A case report. Clin Orthop Relat Res. 1994;308:98-101.

Miniaci A; Gish MW. Management of anterior glenohumeral instability associated with large Hill-Sachs defects. Tech Shoulder Elbow Surg. 2004;5:170-5.

Cho SH; Cho NS; Rhee YG. Preoperative analysis of the Hill-Sachs lesion in anterior shoulder instability: how to predict engagement of the lesion. Am J Sports Med. 2011;39:2389-95.

Sekiya JK; Wickwire AC; Stehle JH; Debski RE. Hill-Sachs defects and repair using osteoarticular allograft transplantation: biomechanical analysis using a joint compression model. Am J Sports Med. 2009;37:2459-66.

Kaar SG; Fening SD; Jones MH; Colbrunn RW; Miniaci A. Effect of humeral head defect size on glenohumeral stability: cadaveric study of simulated Hill-Sachs defects. Am J Sports Med. 2010;38:594-9.

Bigliani LU; Newton PM; Steinmann SP; Connor PM; McIlveen SJ. Glenoid rim lesions associated with recurrent anterior dislocation of the shoulder. Am J Sports Med. 1998;26:41-5.

Lo IK; Parten PM; Burkhart SS. The inverted pear glenoid: an indicator of significant glenoid bone loss. Arthroscopy. 2004;20:169-74.

Boileau P; Villalba M; Héry JY; Balg F; Ahrens P; Neyton L. Risk factors for recurrence of shoulder instability after arthroscopic Bankart repair. J Bone Joint Surg Am. 2006;88:1755-63.

Yamamoto N; Itoi E; Abe H; Kikuchi K; Seki N; Minagawa H; Tuoheti Y. Effect of an anterior glenoid defect on anterior shoulder stability: a cadaveric study. Am J Sports Med. 2009;37:949-54.

Jobe FW; Giangarra CE; Kvitne RS; Glousman RE. Anterior capsulolabral reconstruction of the shoulder in athletes in overhand sports. Am J Sports Med. 1991;19:428-34.

Wirth MA; Groh GI; Rockwood CA Jr. Capsulorrhaphy through an anterior approach for the treatment of atraumatic posterior glenohumeral instability with multidirectional laxity of the shoulder. J Bone Joint Surg Am. 1998;80:1570-8.

Warner JJ; Johnson D; Miller M; Caborn DN. Technique for selecting capsular tightness in repair of anterior-inferior shoulder instability. J Shoulder Elbow Surg. 1995;4:352-64.

Gerber C; Werner CM; Macy JC; Jacob HA; Nyffeler RW. Effect of selective capsulorrhaphy on the passive range of motion of the glenohumeral joint. J Bone Joint Surg Am. 2003;85:48-55.

Lusardi DA; Wirth MA; Wurtz D; Rockwood CA Jr. Loss of external rotation following anterior capsulorrhaphy of the shoulder. J Bone Joint Surg Am. 1993;75:1185-92.

Rowe CR; Zarins B; Ciullo JV. Recurrent anterior dislocation of the shoulder after surgical repair. Apparent causes of failure and treatment. J Bone Joint Surg Am. 1984;66:159-68.

Young DC; Rockwood CA Jr. Complications of a failed Bristow procedure and their management. J Bone Joint Surg Am. 1991;73:969-81.

Tauber M; Resch H; Forstner R; Raffl M; Schauer J. Reasons for failure after surgical repair of anterior shoulder instability. J Shoulder Elbow Surg. 2004;13:279-85.

Araghi A; Prasarn M; St Clair S; Zuckerman JD. Revision anterior shoulder repair for recurrent anterior glenohumeral instability. Bull Hosp Jt Dis. 2005;62:102-4.

Balg F; Boileau P. The instability severity index score. A simple pre-operative score to select patients for arthroscopic or open shoulder stabilisation. J Bone Joint Surg Br. 2007;89:1470-7.

Cooper RA; Brems JJ. The inferior capsular-shift procedure for multidirectional instability of the shoulder. J Bone Joint Surg Am. 1992;74:1516-21.

Pollock RG; Owens JM; Flatow EL; Bigliani LU. Operative results of the inferior capsular shift procedure for multidirectional instability of the shoulder. J Bone Joint Surg Am. 2000;82:919-28.

Zabinski SJ; Callaway GH; Cohen S; Warren RF. Revision shoulder stabilization: 2- to 10-year results. J Shoulder Elbow Surg. 1999;8:58-65.

Levine WN; Arroyo JS; Pollock RG; Flatow EL; Bigliani LU. Open revision stabilization surgery for recurrent anterior glenohumeral instability. Am J Sports Med. 2000;28:156-60.

Millett PJ; Clavert P; Warner JJ. Arthroscopic management of anterior, posterior, and multidirectional shoulder instability: pearls and pitfalls. Arthroscopy. 2003;19 Suppl 1:86-93.

Krishnan SG; Hawkins RJ; Horan MP; Dean M; Kim YK. A soft tissue attempt to stabilize the multiply operated glenohumeral joint with multidirectional instability. Clin Orthop Relat Res. 2004;429:256-61.

Marquardt B; Garmann S; Schulte T; Witt KA; Steinbeck J; Pötzl W. Outcome after failed traumatic anterior shoulder instability repair with and without surgical revision. J Shoulder Elbow Surg. 2007;16:742-7.

Cheung EV; Sperling JW; Hattrup SJ; Cofield RH. Long-term outcome of anterior stabilization of the shoulder. J Shoulder Elbow Surg. 2008;17:265-70.

Topics

repeat surgery ; shoulder region ; shoulder instability ; stabilization ; shoulder dislocation open reduction

First Page Preview

View Large

Username

Password

Access for Patients

Forgot Password?

Have a subscription to the print edition?

Not a Subscriber?

Buy this Article

Get online access for 30 days for $35

New to JBJS?

Subscribe to the online edition for 30 days for $75

Register for a FREE limited account to get full access to all CME activities, to comment on public articles, or to sign up for alerts.

Have a subscription to the print edition?

Current subscribers to The Journal of Bone & Joint Surgery in either the print or quarterly DVD formats receive free online access to JBJS.org.

Activate your online account now

Forgot your password?

Enter your username and email address. We'll send you a reminder to the email address on record.

Username:*

Email Address:*

Forgot your username or need assistance? Please contact customer service at subs@jbjs.org. If your access is provided
by your institution, please contact you librarian or administrator for username and password information. Institutional
administrators, to reset your institution's master username or password, please contact subs@jbjs.org

References

Accreditation Statement

These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.

CME Activities Associated with This Article

Submit a Comment

Please read the other comments before you post yours. Contributors must reveal any conflict of interest.
Comments are moderated and will appear on the site at the discretion of JBJS editorial staff.

* = Required Field

Comment Author(s) * (if multiple authors, separate names by comma)

Example: John Doe

Affiliation & Institution*

Disclosure

Comment Title*

Comment*

Cancel

Print
PDF
Email

Recipient(s) will receive an email with a link (good for 5 days) to 'Revision Open Capsular Shift for Atraumatic and Multidirectional Instability of the Shoulder'.
Your Name:*
Example: John Doe

Email Address:* CC Me:
Enter your valid email address. Example: jdoe@example.com

Recipient's Email Address:*

Separate multiple email address with semi-colons (up to 5).

Subject:* 's The Journal of Bone & Joint Surgery: 'Revision Open Capsular Shift for Atraumatic and Multidirectional Instability of the Shoulder'
Subject for your email.

Message:

(Optional, message will truncate at 1000 characters)

Processing your request... Please Wait...

Copyright © in the material you requested is held by The Journal of Bone & Joint Surgery, Inc. (unless otherwise noted). This email ability is provided as a courtesy, and by using it you agree that that you are requesting the material solely for personal, non-commercial use, and that it is subject to Journal of Bone & Joint Surgery, Inc.'s Terms of Use. The information provided in order to email this topic will not be used to send unsolicited email, nor will it be furnished to third parties. Please refer to The Journal of Bone & Joint Surgery Inc.'s Privacy Policy for further information.

Copyright © The Journal of Bone & Joint Surgery Inc. All rights reserved.
Share
Get Citation

Aaron J. Bois, Michael A. Wirth; Revision Open Capsular Shift for Atraumatic and Multidirectional Instability of the Shoulder. The Journal of Bone & Joint Surgery. 2012 Apr;94(8):748-756.

Download citation file:

RIS (Zotero)

EndNote

BibTex

Medlars

ProCite

RefWorks

Reference Manager

Copyright © The Journal of Bone and Joint Surgery, Inc.
Rights & Permissions
Article Alerts

Processing your request... Please Wait.
Submit a Comment